post op visit code

• For Ophthalmologists
• For Practice Management
• For Clinical Teams
• For Public & Patients

Museum of the Eye

• Managing Your Practice
• Managing Your Practice Topics
• Emergency Preparedness and Cybersecurity
• Practice Forms Library
• Practice Management News & Advice
• Lean Management
• Video Library
• My Green Doctor
• Ophthalmology Job Center
• Benchmarking & Salary Tools
• Academy Consultations
• Consultant Directory
• Coding Topics
• Ask the Coding Experts
• Cataract Surgery
• Codequest Events
• Coding for Injectable Drugs
• EM Documentation
• Ophthalmic Coding Specialist (OCS) Exam
• Savvy Coder
• Submit an Instruction Course
• Codequest Courses
• Mid-Year Forum
• Webinar Recordings
• Upcoming Webinars
• IRIS Registry
• Merit-Based Incentive Payment
• Medicare & MIPS
• Promoting Interoperability
• Improvement Activities
• Avoid a Penalty
• Medicare Participation Options
• Medicare Advantage Plans
• New Medicare Card
• Provider Enrollment, Chain and Ownership System (PECOS)
• Membership Benefits
• Renew/Pay Dues
• AAOE Membership
• AAOE Board of Directors
• Practice Views
• AAOE Content Committee
• Volunteer Opportunities
• For Practice Management /

Postoperative Visit Reporting

Starting Jan. 1, 2017, the Centers for Medicare and Medicaid Services will collect postoperative visit data from group practices in nine states . Starting July 1, affected providers must report CPT code 99024 Postoperative visit for minor (10-day) and major (90-day) surgical procedures, through the usual process for filing claims.

• States affected: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island. (CMS encourages practitioners in other states to report postoperative visits even if they’re not required to.)
• Practices affected: Groups of 10 more physicians and non-physician (MD, DO, OD, PA, NP) practitioners.
• Ophthalmology CPT codes: 11200, 11440, 11441, 11442, 11443, 12051, 12052, 13151, 13152, 14040, 14041, 14060, 14061, 15120, 15260, 15823, 17110, 17280, 17281, 17282, 17283, 37609, 64612, 64615, 65756, 65855, 66170, 66179, 66180, 66711, 66761, 66821, 66982, 66984, 67036, 67040, 67041, 67042, 67108, 67113, 67145, 67210, 67228, 67255, 67800, 67840, 67900, 67904, 67917, 67924, 68760, 68761, 68801, 68810 and 68840. See detailed listing below.

Beginning in 2019, CMS may use the information collected, along with any other available data, to improve the accuracy of valuation for surgical services.

List of Procedures Ophthalmologists Are Required to Report for CMS Surgical Data Collection Effort

How to report postoperative visits performed July 1 and after

The CMS data-collection project applies to Medicare Part B patients only. You do not need to report visits for patients on other insurance or in Medicare Advantage plans. Tip: Test your system and billing services before July 1, 2017 to ensure your software and staff are ready.

• Schedule only medically necessary postoperative visits with the physician.
• Report only face-to-face postoperative care related to the surgery, including the surgical diagnosis (no phone calls).
• Include the practitioner, beneficiary and date of service in the claim.
• If your practice management system or clearing house won’t submit a CPT code without a charge, put in $0.01 and write it off.

Who should report:

• Teaching physicians should follow the usual CMS policies for reporting CPT code 99024 using the GC or GE modifier as appropriate.
• Include visits to patients you see postoperatively, whether or not you performed the original surgery.
• If you co-manage with other providers, both of you should report your postoperative visits, whether you share a practice or not.

Applicable settings:

• The practice setting does not matter. Include visits performed in the office, ED, hospital or skilled nursing facility.
• Practices with offices in multiple states should report postoperative visits based on where you performed the surgery. (E.g., report postop visits in Washington if the patient received surgery in Oregon.)

How to handle other services:

• If you perform others exams during the global period, only bill for exams recognized as unrelated to postoperative care; append modifier -24.
• You may also report postop visits for other codes, if desired.

CMS has not yet announced the remittance-advice code associated with 99024.

Background on the data-collection project

The Medicare Access and CHIP Reauthorization Act of 2015 barred CMS from eliminating 10- and 90-day global surgical payments, which the agency deemed misvalued. Instead, the law authorized CMS to collect data on such services to review the valuation of surgical services from a representative sample of physicians.

• Performed by more than 100 practitioners and 10,000 times; OR
• Procedures with allowed charges exceeding $10 million.
• The AMA Relative Value-Scale Update Committee proposed this method. CMS originally wanted to survey all codes with 10- or 90-day global periods.
• Data collection began Jan. 1, 2017.
• CMS will use the collected information to look at the number and level of medical visits furnished during the global period, plus other items and services related to the surgery, as appropriate.

Additional resources

• Email questions to [email protected]
• CMS Global Period Fact Sheet  [PDF]
• CMS webinar slides  [PDF]

All content on the Academy’s website is protected by copyright law and the  Terms of Service . This content may not be reproduced, copied, or put into any artificial intelligence program, including large language and generative AI models, without  permission from the Academy.

• About the Academy
• Jobs at the Academy
• Financial Relationships with Industry
• Medical Disclaimer
• Privacy Policy
• Terms of Service
• Statement on Artificial Intelligence
• For Advertisers

FOLLOW THE ACADEMY

Medical Professionals

Public & Patients

99024 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Examples

The current procedural terminology (CPT) describes the postoperative follow-up visit with the 99024 CPT code.

Description Of The 99024 CPT Code

CPT code 99024 usually comprises the surgical package to designate that the provider did perform an evaluation and management service during a postoperative period for reasons related to the original procedure.

Official description CPT code 99024: “Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure . “

The provider performs an E/M examination during the global surgical period for surgery; the patient already had gone through it before.

The global surgical package, also called global surgery, includes all the compulsory services generally supplied by a surgeon before, during, and after a procedure.

Medicare payment for a surgical procedure consists of preoperative and intra-operative.

The provider typically performs the postoperative services or associates of the same group with the same specialty.

Billing Guidelines

While submitting the postoperative follow-up visit, first understand the usage of the 99024 CPT Code.

It is a Medicare bundled code with zero relative value units (RVUs). And it has no fee on the Medicare Physician Fee Schedule (MPFS); CMS is interested in collecting this information.

Medicare may reimburse bundled code, but not when the provider has performed the service.

Because government insurance pays for the service in advance, it is suitably interested in whether the provider performs it.

Thorough postoperative care minimizes the risk of surgery problems, including pain, helps manage the side effects of the procedure, and supports recovery.

There are some general guidelines for postoperative period billing.

The same provider executes a distinct procedure or evaluation and management service during a postoperative period.

The coder or biller may use two modifiers to simplify billing for visits and other methods in the postoperative period of a surgical procedure but not included in the payment for the surgical procedure.

Modifier 79 narrates the process (unrelated) or service by the same physician during a postoperative time.

The health professional may need to indicate that a function or service furnished during a postoperative period was unrelated to the original procedure.

A new postoperative period begins when someone bills the irrelevant method. Modifier 24 is represented as (unrelated evaluation and management service by the same physician during a postoperative period).

The physician may need to indicate that he provides the assessment and management service during an unrelated procedure’s postoperative period.

An E/M service billed with modifier 24 medical notes must support that the service is irrelevant to the postoperative care of the technique.

The CPT 99024 , when performing an evaluation and management service during a global period , is related to the procedure for which the patient is in the worldwide period. It applies to services with 10–and 90–day global periods.

Some have viewed the reporting of this code as optional because it is not associated with any payment.

Knowing those who practice (in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island) is essential.

When it is appropriate, the Centers for Medicare and Medicaid Services (CMS) require CPT 99024 in those states.

While submitting the postoperative follow-up visit (CPT 99024), one must report these visits through the normal process for filing a claim.

The coder or biller should submit provider, patient, and date-of-service information for claim submission.

The postoperative visit (CPT 99024) does not need to link the related 10–day or 90–day global code, and it is not essential to add any modifiers.

The provider should follow standard Medicare billing requirements to determine that he provided the visits and correctly used the code.

Notably, the Centers for Medicare & Medicaid Services (CMS) may use the collected data to revalue surgery CPT codes.

Therefore, providing complete and precise information about postoperative visits is critical.

Correct usage of postoperative follow-up CPT 99024 is also applied in teaching hospitals and to services provided by residents. Moreover, the provider must be present during postoperative follow-up visits in the primary or critical portions of the service.

The reporting requirement dictates using the 99024 CPT code for all postoperative visits in the global package, not just office visits .

CMS states it in its Global Surgery Data Collection Requirement. Reporting the 99024 CPT code for all postoperative follow-up visits is mandatory.

But it must be during the global period, regardless of the postoperative care setting.

The CPT code 99024 for postoperative care will help ensure surgeons are reimbursed sufficiently for all their work.

And help postoperative physician visits achieve better health results for patients

Billing Examples

The following are examples of when the 99024 CPT code can be used.

A 44 – year old patient was seen in the provider’s office five days ago with a 2.5 – cm laceration to the right anterior side of the wrist. An intermediate layered closure was performed ( CPT code 12031 ).

The same patient now presents with redness, swelling, and drainage to the sutured area. The final diagnosis was infected laceration.

The coder correctly gives the following CPT code, in this case, 99024 CPT code Postoperative Follow-Up Visit, Included Surgical Package, E&M Performed.

The modifier is not acceptable because all services go under the code assigned.

In the second example, a 56 – year old male patient was seen in the provider’s office 30 days ago for permanent sterilization or contraception ( CPT 55250 ).

The same patient again visits the provider’s office to confirm the complete sterilization in the semen test. There is no reason for the visit to sterilize (ICD – 10 CM code Z30.2).

After reviewing the previous surgical data and current medical notes, the coder suggests CPT code 99024 as a postoperative follow-up visit and diagnosis code Z30.2.

Similar Posts

How to use cpt code 55862.

CPT 55862 describes the surgical exposure of the prostate, which involves the insertion of radioactive material and lymph node biopsy(s). This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples. 1. What is CPT Code 55862? CPT 55862 is used to describe the…

How To Use CPT Code 70543

CPT 70543 is a code for magnetic resonance imaging (MRI) of the orbit, face, and/or neck with and without contrast material. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 70543 procedures. 1. What is CPT 70543? CPT…

How To Use CPT Code 95165

CPT 95165 describes the professional services for the supervision and provision of antigens for allergen immunotherapy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples. 1. What is CPT Code 95165? CPT 95165 can be used to describe the professional services provided…

How To Use CPT Code 97112

CPT 97112 describes the therapeutic procedure of neuromuscular reeducation for movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples. 1. What is CPT Code 97112? CPT 97112 is a…

How To Use CPT Code 15835

CPT code 15835 describes the excision of excessive skin and subcutaneous tissue, including lipectomy, of the buttock. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples. 1. What is CPT Code 15835? CPT 15835 is used to describe the surgical procedure of removing excessive…

How To Use CPT Code 38531

CPT 38531 describes the biopsy or excision of lymph node(s) in the inguinofemoral region. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples. 1. What is CPT Code 38531? CPT 38531 is used to describe the biopsy or excision of lymph node(s) in the…

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Continue Reading

More in FPM

More in pubmed.

Copyright © 2021 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

I'm looking for

• Foundation for Women’s Cancer
• Risk Factors
• First Appointment
• Diagnostic Tests
• Treatment Options
• Post Treatment
• Lynch Syndrome
• Clinical Trials
• Survivorship Toolkit
• Search Site

Coding Corner: When is a Post-op Visit Not a ‘Post-op Visit’ | Kimberly Levinson, MD, MPH

Kimberly Levinson, MD, MPH

The post-operative period has variable length depending on the procedure (0, 10, or 90 days), and specific post-operative services are included in the global surgery payment. However, there are times when a patient may be seen during the post-operative period where the services rendered should not be considered part of the global and are billable separately.

Post-op services included in the global period

• Dressing changes
• Local incisional care
• Removal of operative packing or closing material (i.e. staple removal)
• Insertion, irrigation, or removal of urinary catheters
• Intravenous lines, nasogastric tubes, rectal tubes
• Removal of tracheostomy tubes
• Post-operative pain management
• Complications from a surgery

Complications related to the surgical procedure that do NOT require a return to the operating room are included in the global package

• A patient’s room, recovery room, ICU, or a minor treatment room are NOT considered an operating room and services provided in these locations can NOT be billed separately

Post-op services that should be billed separately and are NOT included in the global period

• For gynecologic oncologists who administer chemotherapy, a visit in which treatment with chemotherapy is discussed should be billed separately
• A modifier -79 should be used
• A modifier -24 should be used
• An operating room may include a cardiac cath suit, laser suite, or endoscopy suite, but not a patient’s room, recovery room, ICU, or minor treatment room
• A modifier -78 should be used
• This may include a radical hysterectomy following conization
• A modifier -58 should be used
• A modifier -55 should be used

More information can be found about the global period on the CMS website .

Excel files with the global period (0,10, or 90 days) can be downloaded from the CMS website .

Kimberly Levinson MD MPH is Director of Johns Hopkins Gynecologic Oncology at GBMC; Assistant Fellowship Director at Kelly Gynecologic Oncology Service; Assistant Residency Director at Department of Gynecology and Obstetrics and Assistant Professor at  Johns Hopkins University School of Medicine.

Related Resources

• Private Practice Pricing
• DSO/Group Pricing
• OMS Pricing
• Dental Events Calendar
• Dental Billing Books
• DCS on YouTube
• Testimonials

«  View All Posts

Defining CDT Codes: What is CDT code D9430?

• Share This Article

March 7th, 2024 | 6 min. read

Dilaine Gloege

Print/Save as PDF

Current Dental Terminology (CDT) coding is no easy walk in the park. There are dozens of codes to choose from when creating an insurance claim, and codes are changed, added, and deleted every year.

With their intricacies and frequent changes, code selection can be confusing when a patient’s treatment and reason for treatment are not straightforward. 

But as a dental professional, it’s vital to get these CDT codes right — your insurance claims revenue depends on it. Dr. Bicuspid explains it well: 

“Choosing the correct code is about selecting the most current code that fits the procedure, not a code that paid in the past or one that you have always used in the same circumstance.”

Code D9430 is a code we see questioned pretty often, so we’re clearing up the confusion with this article. But how do we know what’s correct?

Well, since 2012, we’ve helped dental teams understand and stay current with CDT codes. Our billing experts are part of what we call The DCS Knowledge Network . It’s our pool of insurance billing specialists who confidently stay up to date on all things dental insurance — including coding.

This article will explain the difference between the often mismanaged: CDT code D9430, CDT code D0140, and CDT code D0171. Recognizing the difference between these CDT codes will ensure proper use of each code to avoid claim denials due to coding errors. 

• CDT Code D9430 explained — Understanding the observation visit

Let’s first look at the descriptor of D9430 . 

D9430 office visit for observation (during regularly scheduled hours) ⎼ no other services performed

Two key phrases in the D9430 nomenclature are “during regularly scheduled hours” and “no other services performed”. No other services performed includes evaluations in addition to any treatment. The phrase “no other services” does not include post-operative oral hygiene home care instructions. 

Sometimes you just need to bring the patient back for observation following treatment when the office is usually open. This is a common use of code D9430, and it seems simple enough. But….

Related: CDT Codes: Current Dental Terminology explained

How does CDT Code D9430 relate to D0140, D0171, and D9440?

Next, let’s define code D0140 .

D0140 limited oral evaluation – problem focused

This suits an evaluation limited to a specific oral health problem or complaint, and it may require interpretation of information acquired through additional diagnostic procedures. Be sure to report additional diagnostic procedures separately with their appropriate codes. 

Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc. 

D0140 may be reported for a new or established patient. This is not to be reported when a comprehensive oral evaluation was actually performed, however. A few examples of a limited oral evaluation include:

• Evaluation of an emergency patient presenting with a problem or pain
• Evaluation of tooth replacement such as implant placement
• Any other specific problem where the evaluation specifically addresses one problem, limited area of the oral cavity, or complaint.

But what about D0171 ?

D0171 re-evaluation – post-operative office visit

This code was created to give providers a way to document post-operative visits. Most dental plans consider a re-evaluation post-operative visit inclusive to the procedure being performed.

Consider that the global period for inclusive follow-up care may be defined as 30 days for restorations such as fillings, or 6 months following delivery of appliances such as dentures. 

And what is D9440 ?

D9440 office visit – after regularly scheduled hours

Similar to D9430, but the difference here is the office visit is completed after hours.

How do I apply CDT Code D9430 in my dental office?

Now that we’ve defined each code, let’s go through a scenario in which you could apply CDT code D9430 instead of the others.

The patient presented for two post-operative visits. At the first post-operative visit, sutures were removed and oral hygiene home care instructions related to the surgical area were provided.

The CDT code for oral hygiene instructions is D1330. Most dental plans consider instructions a part of the visit, so they are not billed separately. Still, you would include D1330 for documentation purposes.

So, for post-op visit #1, you would use the codes:

D1330 oral hygiene instructions were reported for the first post-operative visit

Six weeks later, at the second post-operative visit — the final post-operative appointment — either D0171 or D9430 can be used, depending on whether additional treatment was performed or not. If there was additional treatment, then the following codes would be appropriate::

D0171 re-evaluation post-operative office visit

D1330 oral hygiene instructions

Or if additional treatment wasn’t performed, the appropriate codes would be:

D9430 office visit for observation (during regularly scheduled hours) – no other services performed

Remember to include D1330 and other non-billable codes even though they aren’t reimbursed. Precise documentation is necessary for both medical and legal reasons, so it’s important to code everything that was performed, whether or not insurers will pay foor it.

Now, here’s a scenario where D9430 would not be used…

The patient presented for an emergency visit complaining of pain in the lower right, pointing to tooth #31. One periapical radiograph was captured, and the doctor performed an evaluation.

A radiographic image revealed a suspicious area at the apex of the tooth. No treatment was performed. The patient was referred to the endodontist for further evaluation of possible abscesses. The following codes would be used to document and report this emergency visit.

D0140 evaluation – problem focused

D0220 periapical x-ray – first image

Note that code D9430 could not be billed in this circumstance, because D9430 specifies no other services were performed, and D0220 is considered another service.

Confused? Access our DCS Knowledge Network

Documentation is key to claim acceptance, and as you see in the examples above, it can be quite specific. Your team should always document and report what was performed by following the current CDT code set. Train them on accurate code selection and maintain a current CDT manual for their reference. 

It is worth noting that D0171 is most often considered part and parcel of the original treatment, and with a PPO plan, D0171 will be denied and written off. However, codes D9430 and D9440 are usually considered a non-covered service, and they can be billed to the patient, even with a PPO plan. 

As always, coding should be determined by what was actually done. A patient’s available dental benefits, or lack thereof, should not determine the code used to document and report. But if there is an opportunity to decide which code to choose, knowing your compliant alternative code options will be useful.

Code confidently with the DCS Knowledge Network on your side

At DCS, we know CDT coding is challenging and oftentimes confusing. As we mentioned in the beginning of this article, we’ve been helping dental teams sort out code confusion since 2012 — we may not have seen it all, but we have certainly seen a lot!

To recap, in this article on CDT Code D9430, we covered:

• How CDT Code D9430 relates to Codes D0140, D0171, and D9440
• How to apply CDT Code D9430 in your dental office

Accurate coding keeps your dental practice compliant, leads to faster reimbursement on insurance claims, and also helps your practice stay out of legal trouble. It’s crucial that your team understands the nuances of these codes and stays current on CDT coding changes and updates.  

If you still feel a lost or overwhelmed by these CDT codes or others, don’t worry! The DCS Knowledge Network is here to support your team through the entire insurance claims process. 

Our full-service revenue cycle management services include experts checking that your team is coding correctly. Our team’s support will increase your team’s confidence and lead to higher collections, plus more consistent revenue for your practice. 

Don’t let CDT coding keep you down: Book a free 30-minute call with DCS today.

Related Posts

Dental billing resources

What the Aftercare? How to Use Z Codes in ICD-10

Let’s talk about Z codes in ICD-10—and what they have to do with post-surgical aftercare.

Get the latest news and tips directly in your inbox by subscribing to our monthly newsletter

Rehab therapists are restoration specialists. Not only do they work to restore musculoskeletal function after an illness or injury, but they also restore patients’ confidence in their movement and functional capabilities. In most cases, therapists see patients after they’ve experienced some type of disruptive event—like an injury, an illness, or a surgical procedure. But that doesn’t mean therapists should exclusively use aftercare codes, as Z codes in ICD-10 apply only in very select circumstances. 

So, when it comes to how to use Z codes in aftercare, rehab therapists should keep the following advice in mind.

Aftercare Z codes in ICD-10 are not meant to be used with seven-character codes.

ICD-10 introduced the seventh character to streamline the way providers denote different encounter types—namely, specific situations involving active treatment versus those involving subsequent care. However, not all ICD-10 diagnosis codes include the option to add a seventh character. For example, most of the codes contained in chapter 13 of this resource (a.k.a. the musculoskeletal chapter) do not allow for seventh characters. And that makes sense considering that most of those codes represent conditions—including bone, joint, and muscle conditions that are recurrent or resulting from a healed injury—for which therapy treatment does progress in the same way it does for acute injuries.

Codes for acute injuries (mainly found in chapter 19) and fractures, however, do allow for seventh characters. And when you use the seventh character “D,” you are denoting that the patient is in the healing/recovery phase of their treatment. Essentially, you are indicating that these are situations where patients are receiving aftercare for the injury. Thus, you should not use aftercare codes in conjunction with injury codes, because doing so would be redundant.

Don’t let Z codes stump you ever again. Pick the right codes every time with the WebPT EMR’s intelligent ICD-10 selector.  

Use z codes to code for surgical aftercare..

When a patient's health status necessitates continual care during a post-treatment healing or recovery phase—or when they require care for chronic symptoms that resulted from their original ailment—aftercare visit codes perfectly fit the bill. Z codes also apply to post-op care when the condition that precipitated the surgery no longer exists—but the patient still requires therapeutic care to return to a healthy level of function. These situations often provide common Z codes for therapists that include:

• Z47.89, Encounter for other orthopedic aftercare, and 
• Z47.1, Aftercare following joint replacement surgery. 

Remember, there are several orthopedic aftercare codes for specific surgeries—all of which you can find in this ICD-10 resource under Z47, Orthopedic aftercare.

{{inline-form}}

A single aftercare code might not be enough.

In specific situations where it’s appropriate to use Z codes in ICD-10, aftercare codes may be the principal first-listed diagnosis code—but that doesn’t mean the Z code should be the only diagnosis code listed for that patient. You should submit secondary codes—including other Z codes—when they can help you fully describe the patient’s situation in the most specific way possible. 

For example, if you were treating a patient who had a total knee replacement, you would want to submit Z47.1, Aftercare following joint replacement surgery, as well as Z96.651 (to indicate that the joint replaced was the knee). Taking this one step further, let’s say the patient was receiving treatment for gait abnormality following a total knee replacement of the right knee due to osteoarthritis in that knee. Let’s also assume that, as a result of the surgery, the patient is no longer suffering from osteoarthritis. The appropriate codes for this scenario, according to this presentation , would be:

• ICD-10: Z47.1, Aftercare following surgery for joint replacement
• ICD-10: Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant
• ICD-10: R26.9 Abnormality, gait

If you’re still a little fuzzy on how to use Z codes in ICD-10, just remember that in most cases, you should only use aftercare codes if there’s no other way for you to express that a patient is on the “after” side of an aforementioned “before-and-after” event. So, go ahead and use an aftercare code after you’ve exhausted all other coding options. (See what I did there?)

Have another tricky billing question? Check out this handy PT billing FAQ.

Have more questions about ICD-10?

Related posts.

Why Experience and Expertise Matter for Rehab Therapy Software

Finding the Right ICD-10 Code For Sciatica

How to Use the ICD-10 Code for Difficulty in Walking

Learn how WebPT’s PXM platform can catapult your practice to new heights.

Politics latest: Yousaf quits as Scotland's first minister

Humza Yousaf has announced his resignation as SNP leader and Scotland's first minister following the fallout from his decision to end the SNP's powersharing agreement with the Scottish Greens.

Monday 29 April 2024 14:20, UK

Please use Chrome browser for a more accessible video player

• Yousaf quits as Scottish FM after ending powersharing deal
• Outgoing SNP leader admits he 'underestimated' hurt caused
• Analysis: The biggest political miscalculation of Yousaf's career
• Explained: How did we get here - and what happens next?
• Analysis:  Tories expect elections pounding - but Labour may have harder job
• Watch in full: Trevor Phillips interviews the prime minister
• Tap here to follow Politics At Jack And Sam's
• Live reporting by Samuel Osborne

The leader of the Scottish Conservatives, Douglas Ross, has said the outgoing first minister "decided to jump before he was pushed" by announcing his resignation today.

Humza Yousaf "knew his future was on a knife edge" as he faced up to two confidence votes this week, Mr Ross said, adding he had quit "because of the pressure we had put on as the main opposition party".

But there was no sign of Mr Ross and the Scottish Tories looking to offer their backing for a new SNP first minister.

Having seen off Mr Yousaf, Mr Ross said his party was now focused on "seeking to replace this tired, failing, nationalist government who have prioritised independence above everything else".

Holyrood is in a "terrible situation" following the resignation of Scotland's first minister, one of Humza Yousaf's predecessors has said.

Henry McLeish, who was first minister under Labour from 2000 until 2001, said while Mr Yousaf had shown "a bit of grace" and "humility" by quitting today - there was "no way he could continue in office".

He told Sky News his decision to end the SNP's powersharing deal with the Scottish Greens was more evidence of how "politically divided" Scotland had become.

Mr McLeish told Sky News his homeland is in desperate need of some "unity" and called for all parties to start thinking like a "coalition", even if not in practice.

Labour's call for an immediate election at Holyrood is - like their demand for one at Westminster - not likely to go anywhere, he added.

Humza Yousaf has announced he is standing down as Scotland's first minister and SNP leader.

Our Scotland reporter Jenness Mitchell reports on some of the potential contenders who could step up to lead the country:

Former SNP leader John Swinney has said he is giving "very careful consideration" to standing to replace Humza Yousaf after he announced his resignation as first minister of Scotland.

Mr Swinney said: "I've been somewhat overwhelmed by the requests that have been made of me to do that, with many messages from many colleagues across the party.

"So I'm giving that issue very active consideration. And it's likely I'll have more to say about that in the days to come."

He added: "I'm very sorry that the first minister has decided to stand down.

"He's been a pioneer as first minister, the first person of colour to hold the office of first minister of Scotland.

"He's led our country with empathy, with care and with an emphasis always on bringing people together, so I very much regret the fact he's felt it necessary today to stand down."

 It is "bizarre" that some SNP MSPs would rather see Humza Yousaf resign as Scotland's first minister than do a deal with the pro-independence Alba Party, Ash Regan has said.

Ms Regan's support may have been needed to get Mr Yousaf over the line in a confidence vote.

The former SNP politician, who leads Alba in Holyrood and is the party's first MSP, said: "The irony will not be lost on many that the event that has cost Humza Yousaf his job was removing the Greens from government - something most people in Scotland agreed with.

"Alba Party were willing to work in the best interests of Scotland to put independence back at the heart of government, protect the rights of women and girls, and to get the government back on to a competent footing.

"The Greens were willing to vote with the Tories and bizarrely some forces in Humza Yousaf's own party would rather see him resign than deal with a party who really want to advance independence."

Humza Yousaf "doesn't have the X factor" and was right to stand down as Scotland's first minister, the former deputy leader of the SNP has said.

Jim Sillars said: "Humza has been what I would describe as a follow-up, not a leader.

"And that came through when he was a candidate for the leadership, when he described himself as the continuity candidate - in other works Nicola Sturgeon Mark II.

"And he was never able to rid himself of the Sturgeon legacy because he actually saw nothing wrong with it, which was actually mess and mediocrity.

"Nice man though he is, Humza never had what was required."

He said he thought former SNP leadership candidate Kate Forbes was the "outstanding candidate" to take over as leader.

Scotland's First Minister Humza Yousaf has resigned in the face of two confidence votes after he dramatically brought the power-sharing deal with the Scottish Greens to an end.

How did we get here?

The Bute House Agreement - signed back in 2021 and named after the first minister's official residence in Edinburgh - brought the Green Party into government for the first time anywhere in the UK.

It gave the SNP a majority at Holyrood when the votes of its MSPs were combined with those of the seven Green members, and also made Green co-leaders Patrick Harvie and Lorna Slater junior ministers.

Without it, the SNP would need to have operated as a minority administration at Holyrood.

What caused the relationship to sour?

There had been mounting tensions between the largest party at Holyrood and their junior partners in government.

The Greens were angered at the SNP-led administration's recent decision to ditch a key climate change target.

That, combined with the decision to pause the prescription of new puberty blockers to under-18s at Scotland's only gender clinic, resulted in the Greens announcing they would have a vote on the future of the power-sharing deal. 

What brought things to a head?

Mr Yousaf decided to pull the plug on the agreement - arguing it had "served its purpose" - prompting a major fallout with his former allies, who vowed to back a no-confidence motion in his leadership proposed by Scottish Conservative leader Douglas Ross.

What happens next?

Mr Yousaf said he will continue as first minister until his successor is elected ( see 12.07 post ).

Potential successors include:

• Kate Forbes, former SNP leadership contender;
• Stephen Flynn, leader of the SNP in Westminster;
• Neil Gray, health secretary;
• Jenny Gilruth, education secretary;
• Shona Robison, finance secretary;
• John Swinney, former deputy leader;
• Mairi McAllan, wellbeing economy, net zero and energy secretary.

Humza Yousaf's decision to sack the Green Party from his coalition ultimately triggered a series of events that sealed his political fate, our Scotland correspondent Connor Gillies reports.

"It was the biggest political miscalculation of his career that sealed the fate of the first minister," he said, speaking after Mr Yousaf announced he will step down ( see 12.04 post ).

Ending the three-year powersharing deal at Holyrood was a "fatal mistake" which saw the "walls come closing in".

Those close to Mr Yousaf had suggested that agreement "had become a liability within government and many in the SNP were uneasy about how many strings they were pulling".

"So he got rid of them and that triggered a set of events in motion that ultimately led to this moment and ultimately led to his demise."

No confidence votes

No confidence motions were looming at the Scottish parliament later this week, and he was facing wipeout and a backlash of "no" votes from the Conservatives, Labour, the Liberal Democrats and the Green Party, who were furious. 

"And then at that stage there was a suggestion that the ALBA party, Alex Salmond's party, would prop up the SNP government with their one MSP, Ash Regan," Gillies added. 

"That was just a step too far. Allies and sources close to Scotland's first minister said, 'look, that would be like doing a deal with the devil'. 

"So, there was only one other option and that was to resign."

Stepping in for Sturgeon

Gillies added an "interesting" element to this is how Mr Yousaf said to Sky News just 48 hours ago he would defy that vote of no confidence.

"On a human level, this is a man who is well-liked within the SNP," Gillies said. 

"He is a man who stepped up to the plate when Nicola Sturgeon stepped down last year, and he was always going to have a battle ahead."

But even his closest of allies, Gillies said, would realise "he was not Nicola Sturgeon, and he did not command her authority".

Humza Yousaf gave an emotional end to his resignation announcement.

"I bear no ill will and certainly no grudge against anyone. Politics can be a brutal business," he says.

"It takes its toll on your physical and mental health. Your family suffer alongside you."

Becoming emotional, he adds: "I am in absolute debt to my wonderful wife, my beautiful children and my wider family for putting up with me over the years.

"I'm afraid you'll be seeing a lot more of me from now. You are truly everything to me."

Mr Yousaf continues: "I am so grateful. I'm so blessed for having the opportunity afforded to so few to lead my country, and who could ask for a better country to lead than Scotland? Thank you very much."

Mr Yousaf says he is "incredibly proud" to have a "fair tax system", which he hails as "the most progressive in the UK".

"I've always been guided by my values," he says. 

"As first minister, I'm incredibly proud to have a fair tax system, the most progressive in the UK. 

"But those who earn the most, contribute the most, and it will always be my core belief that a country as rich as ours wealth must be far more evenly distributed." 

He added he has "no doubt at all" that whoever takes over "will continue the Scottish government's drive to reduce child poverty".

"I'm proud that through our actions, an estimated 100,000 children are expected to be lifted out of poverty this year," he claimed.

He also said he will "continue to champion… the rights and the voices of those who are not often heard", including those suffering the "most horrific humanitarian catastrophe" in Gaza.

Be the first to get Breaking News

Install the Sky News app for free